Mwen Pa Konnen

This post is titled "I don't know" in Haitian Creole.  Not just because I said that phrase so many times over the five weeks I spent in Haiti - to the children, to the local staff, in English to the project director - but because ultimately it's the best phrase I can come up with to summarize my experience.  I know perhaps more than I did before I went, but even more sharply I understand there are many things I don't know.

But I supposed I should first finished the story I began way back here and continued earlier this week.

After spending a week and a half planning out how to get Julio an x-ray and an ultrasound, checking the costs, planning how to get to the lab, etc.  We finally had a plan.  Except we didn't go.  

Not because of the costs, although of course everything is ultimately about the cost/benefit ratio, but because over that period of time it became increasingly clear that there was nothing really wrong with our little friend.  If asked, he complains of vague stomach pain that comes and goes every couple of days.  But in the same hour he'll launch himself into a hug with me that betrays no such pain, even with some surreptitious (and then less surreptitious, building up to a rib-cracking hug me tighter contest) taps and squeezes in the area of this "pain."

I don't doubt that he still has a long struggle ahead - he'll still have kidney stones, and have to manage that for probably the rest of his life.  But at least for now we're no longer worried about an acute problem.  I know this doesn't make a perfect story - I'm telling it partly because I hope you might be curious to know how Julio's path continued, but mostly because I feel like it's a great way for me to convey that my time in Haiti didn't particularly make a perfect story.  Didn't fit into boxes, didn't end with a particular bang or a denouement.  The work continues.  The children scramble on, managing health problems, learning deficiencies, developmental delays, and behavioral trails - just as they have for years now.  Sometimes we had great days:  Little Kevens, 7 years old but no bigger than a 5 year old and very learning delayed thanks to severe malnutrition, can tie his sneakers all on his own now.  Somewhere in the madness of driving to the doctor's office, I taught Julio how to subtract bigger numbers.  Leyla can successful identify the color green (and a handful more, if she's focused that second).  I talked with Mica in Creole, made jokes, made her laugh, encouraged her to stand up to the driver, maybe even taught her how to do the accounting work she's supposed to be doing for the garden project.  None of that is glorious.  None of it makes a great finale, but in the end it's that work that I'm the most proud of.  

I spent close to five weeks in Haiti.  I still don't speak Haitian Creole perfectly, and I still don't understand the country at all.  Mwen pa konnen, mwen pa comprann.  I don't know, I don't understand.  But I'm glad I went.  

The End of the Julio's Story

If you're confused what this is continuing, click here to read the beginning of the story.  


To bring you all up to date, Julio’s immediate problems were resolved by a short hospital stay, but the urologist never came to see him (although he did come to the hospital) and none of the prescribed lab tests were even run: several blood tests, a urine culture, and an ultrasound.   Instead he went home with mysterious white pills and a course of antibiotics to deal with the lingering infection. 

About a week later, after dinner in the evening, we found Julio had silently curled himself into a fetal position in the laundry pile.  With considerable effort we were able to get out of him that it hurt.  A lot.  It looked like he was passing another stone.  It was at this point I went on a quest through the unreliable and slow internet to identify the white pills they sent home with him – wanting to know what exactly they were before dosing him with other painkillers.  Turns out I was glad I took the trouble, since they WERE painkillers.  So we let him huddle in the corner for a while with a hot compress on his back while the other kids went up to bed, until eventually he fell asleep.  This launched me on a several day crusade to figure out home treatment for kidney stones - ultimately a futile quest.  One website described it quiet well, noting that one treatment "doesn't actually seem to do anything, but will give your loved ones something to do besides handing you the ibuprofen."  Watching some one, especially a child (even this stoic child), pass a kidney stones is an exercise is feeling useless.  We sat there with him, holding the hot compress, as he lay down and ignored us entirely.  But watching the crisis was a strong reminder that we weren't sure all the loose ends were tied up - was this just about managing kidney stones, or was there something more still wrong?   He was still complaining about back and side pain. . . 

So we went on a an adventure to a urologist in Pètionville – a wealthy suburb of Port-au-Prince.  We frequent Pètionville for shopping and nice lunch breaks from the kids.  It’s relatively easy to get down there and there are lots of things available to buy.  Expatriates of all kinds frequent the area, hearing French and English is not uncommon and foreign faces are a staple of the restaurant businesses.  So.  We set off at 8:30, a mere half hour later than I asked the driver to come get us, but still with plenty of time to wind our way down the single road to the town in the inevitable stop and go traffic.  The driver managed to find us the right street, but we ran into a little trouble with the numbering.  First we stopped outside 75 – we’re looking for 57.  Then we drove along looking for it, and the numbers were going down so I thought we were fine.  But no, the driver spotted a nice-looking clinic on the other side of the street and insisted that was it.  It didn’t appear to have a number, and after all I know nothing about street numbering here so it might well be that things are organized some funny way that 57 is across the street.  But I doubt it, so then he asks someone.  I didn’t understand the whole conversation, but I gathered that he got some directions.  Following these, we blaze down the next block, barely catching a glimpse that there’s another clinic on the corner, and turn around, coming back to the nice-looking place.  The driver stops and encourages us to get out and ask.  So I do, Julio silently following, but it quickly becomes clear that’s not the place we’re looking for so back into the car we go (were I properly Haitian I suppose I would have waited for the front desk attendant to come back to actually ask.  But waiting for things like that can be a long business, just to confirm what I was already confident of).  There was more, but eventually I insisted the driver continue down to the next block, to that clinic we flashed by so quickly, which he did over vocal objections.  Of course that was it.  

The actual medical visit didn't accomplish much of anything - we spoke with the urologist, who couldn't help us without imaging, which he didn't do in his office.  It was comforting, in a way, to talk through the management of the problem with him  - drink lots of water, giving pain killers at a crisis.  But really left us no further ahead.  I then embarked on a several weeks long effort of deciding how, where, and if to get this imaging done. All the phone numbers for the labs were out of date, so each time I wanted to call and get a sense of whether the lab could do the work, and if so, for how much, it was a multiple step process.  Each time I thought I had a plan, I'd talk to some one about it and several reasonable objections would occur, destroying said plan.  Hindering all of this was the fact that the power went out for four days, leaving me with no way to charge the phone I was using.  After much searching, it became clear that the only option was to go all the way down into Port-au-Prince (a much longer and trickier business than sticking to Petionville) to the lab the doc had originally recommended to us (read: we went back to plan #1).

I'll stop there for today - this is getting long.  Check back this weekend for the ending, and a healthy helping of my introspection of my time in Haiti.  

Haiti Books

So as is pretty evident from my blog these past weeks, I'm in Haiti.  Both before going and while there I've been doing a lot of reading.  I'd previously read both "Aids and Accusations" by Paul Farmer and the book about his work by Tracy Kidder, "Mountains Beyond Mountains."  Which spend a little bit of time going into the history of the nation, although they are pretty narrowly focused on the countryside and on health care.  So I wanted to get a little bit of a different story.  I started with "The Serpent and the Rainbow" by Wade Davis.  Davis is an ethnobotanist from Harvard who travels to Haiti in the early eighties on the trail of the truth behind zombis and vodoun.  His account is interesting (but slow getting started, beware: for first you must sit through a long exposition of how he got the gig and why he's an Awesome Explorer) and great if what you're looking for is a somewhat anthropological exploration of vodoun ritual and the science behind zombification.  Both of these things can be fascinating, but portray a very narrow slice of Haiti.  Unmentioned in his entire book is that it takes place in the political context of Jean-Claude "Baby doc" Duvalier's failing regime.  In fact, as Davis waxes eloquent on the brilliance of combining the administration from the goverment and religious divisions of the country in the person of the "Chef de Section" who is often also the local Vodoun priest, he is ignoring that this administration makes sense only in the context of the Duvalier years, in which vodoun was for the first time explicitly permitted, and in fact used as a tool to uphold the dictatorship.

Shifting from his vision of Haiti to Amy Wilentz's "The Rainy Season" is like shifting from a sepia-toned discovery channel special to some kind of MSNBC special report.  A journalist who lived and wrote from Port-au-Prince in the years following Baby Doc's leaving the country, her work is far more urban and political in nature.  Wilentz became quite close to Aristide in the eighties, when he was a persecuted enemy of both the state and the Catholic church hierarchy itself, so her work is peppered with interviews with the man who would later become a massively popular elected president in Haiti.  What's surreal at times about her work read directly after Davis' is that they come from nearly the same timeframe, but feature dramatically differing visions of the same Haiti, sometimes even the same people.  It's from Wilentz that I gleaned that Dulvalier's approach to the Chefs de Section was entirely new, for example.  And both feature the character  Max Beauvoir.  To Davis, he was a well-education Haitian who knew all the secrets of voudoun and set himself up as benevolent guide.  To Wilentz he's a disenfranchised, but still wealthy, member of the elite cadre of Duvalierists who consistently attempts to feed her false stories about Aristide's seditious, at times communist activities.  These stories are usually repeated almost verbatim from another source: Baptist pastor Wally Turnbull, who founded and for many many years ran the Baptist mission at Fermathe.  Yes, the hospital we took Julio to in my first post on Haiti.  Dr. Turnbull is also the author of the Creole course recommended to volunteers here: "Creole Made Easy."  It's a great little course book - a really simple introduction to Creole, which I wish I'd used at home instead of trying to work with the one I had which is much more complex.  Although more complete, that textbook was near impossible for me to get through by myself with no grounding in the language.  But now, knowing a little more background, the Creole Made Easy course seems somehow more suspect. . . or at least limited.

I guess this is less a post about books to read when coming to Haiti (although I would recommend "The Rainy Season" to anyone interested) and more a swirling commentary on how surreal it is to come across so many different visions of the same place, the same people.  This is even more true of the history of the country.  Together with the another volunteer here, I took a little trip to the National Museum.  It's a small place, with a nice collection giving a broad overview of Haitian history, and celebrating the country's four big independence heros:  L'Overture, Christophe, Pètion, and Dessalines.  To look at the museum and hear our guide tell the story is to see these four men as venerated, universally admired pioneers of independence.  All the other books I've read (and the history I'm reading now) tend to depict them as priveledged elites who were less interested in democracy and economic equality and more interested in being the elites who controlled the plantations instead of the whites.

Now, the authors of the books I'm reading are American, and to give him his due I don't think our guide could adequately express himself in English to give a nuanced version of history.  And there is no doubt that we also tend to have an overly venerating attitude towards our founding fathers (an added note of irony for those keeping track:  my visit to the museum took place on July 4th).  But I can't help but notice the conflicting visions which, together with the evidence of stark contrasts in living situations, and the divisiveness and enbattlement of the country's history all lead me to see this country as somehow split.  Both wealthy and poor.  Both extremely well educated and worldly and entirely provincial.  Both modern and stuck in history.

"École Tètè" and other misunderstandings

So all the children here at Kay Grace are out of school for the summer.  This is lovely for them, but could be potentially cray for us, and one of the goals of the project is to help them make up for lost time by giving them some formal structure and education even when not in school.  So Barb has asked us, the two volunteers, to do a kind of small summer camp with them: art projects, organized games both in- and outdoors, and maybe some one-on-one time to work intensively with each child on areas of weakness. We wanted to indicate to the kids that this was something different, and more fun, than regular school - but that it still retained a formality of structure.  That they need to attend, need to listen to us and be prepared to live within rules while there.  So we called it "summer school" or, in my serviceable but not always correct French "L'École d'Été."

Unfortunately, one of the children is called Tètè, and the combination of the indefinite French article and the word for summer slur together in the children's pronunciations so that Summer School becomes Tètè's School: L'École Tètè.  Not a genuine excuse not to come to school, but nonetheless another excuse for them to try on.

While the children delight in teaching us Creole, when they fell like it, and I have come to recently realize that they consistently modify their Creole for us, they also seem to deeply enjoy mocking our language skills.  One of the older boys has a long running joke with me - well it's a joke for him anyway, and after about the millionth repetition I've given in and decided it's a joke for me, too.  He'll wait until I call something bizarre, a not uncommon occurrence given my limited vocabulary of French adjectives.  The i in the French form is long, like pizza rather than like business.  Or rather, like "visa."  So the game goes like this.  I say "C'est bizarre" and he says "Se pa visa, se passport."  If I dare to continue to insist that in fact I said bizarre, with a b, he'll continue to insist that in fact he meant passport.

Just a couple of the small day-to-day challenges dealing with a house full of six children who don't happen to speak your language.  At least they understand me - mostly.

Kindergarten Graduates

This post has nothing to do with medicine.  There, you have been forewarned.

What it does have to do with is the two and half hours I spent on Sunday at a promotion ceremony for the school one of the children here attends.  A promotion ceremony for kindergartners.  Now, to be fair, kindergarten here is three years long. But still.  Two and half hours?  The ceremony was held in a church nearby, which was packed to the gills with families in their best.  The kids were also all dressed up, with the graduates themselves in flashy matching suits and white dresses with green sashes and ribbons.  There were ten of them.

We started the whole shebang off with a song and prayer and introduced the master of ceremonies.  To my surprise, the whole production was in French.  Now, I know that the parents of the child we were going with don't speak French, although the mother understands a lot of it (very helpfully for us volunteers with bad Creole).  So I'm left to wonder how many of the parents really knew what was going on.  The children performed various songs, dances, and poems - all also in french with occasional verse of English (and once, Spanish).  Every single one of them was adorable, of course, but a couple of things struck me as a bit bizarre.  Firstly, the MC was quite talkative, repeatedly exhorting us to applaud the children saying "it's good to clap for children" or "another round of applause for that please, louder, louder!" the response to these commands was not as enthusiastic as might be supposed.  Instead of clapping on demand, the Haitian audience often failed to even half-heartedly applaud in the way American audiences usually do when feeling polite but not particularly impressed.  The second oddball thing, from my perspective, was the way in which increasingly toward the end of the program, the MC started some hardball recruiting. All throughout he had been mentioning the name of the school with an odd frequency, almost like you would a sponsor of a sporting event.  Then as we moved to the second half, in which the graduates (red-robed and crowned with mini mortar boards no less) stood on stages and sang their thanks, received gifts and diplomas (bigger, by the way, than my four-year liberal arts diploma), and very variously feted more directly; the MC moved to explicitly extolling the virtues of the school: "If you want your child to learn English well, French well, really get a good education" enroll in our school.

The recruitment push brings to the fore the fact that here, schools are businesses.  So they charge money to make money, and compete for students to fill their classes.  The whole ceremony was a surprisingly money-visible situation, with an official videographer, custom outfits the students had to buy for the occasion, gifts given, and parents and siblings all parading their best.  I felt truly dumpy in my flip-flops, skirt and polo (the most "dress-up" clothing I had).  It was a striking illustration of how Haiti continually refuses to fit into my boxes.  Yes, the children I'm working with now are desperately poor and their bodies and minds all show signs of that neglect.  But just across the way two and three story houses with manicured gardens, beautifully tiled flooring, new cars, and eight foot high rock walls topped with razor wire.  Just down the hill is Petionville - a wealthy suburb with a store accepting US dollars, several quite nice restaurants and a lovely supermarket with basically anything you'd want.  But then just up the hill in Kenscoff is a tiny shack that used to belong to the mother of three of our kids.  The other volunteer showed me pictures she took when they drove up to move her out and into a small but substantially nicer house we're renting for her.  Having lived in Africa, I suppose I expected things to be more visibly cultural.  More clearly other, more clearly poor.  I'll let you know if I find that Haiti.

Looking down towards Port-au-Prince

I'm too tired to put together much of a post about things, but here's a picture of the view looking down on Port-au-Prince from our hillside: 

Stolen Chickens, Kidney Stones

Dissection posts on hiatus until I come back from Haiti.  Sorry for the bizarre lack of continuity in this medium, but that's how things role.  

So I'm in Haiti.  I have been for about three days now, which have been hectic, tiring, at times awkward days in which I've learned an immense amount of Kreyol (but still nowhere near enough), the day to day schedule of the six children I'm working with here, and mostly that I know next to nothing about Haiti  - even with the reading I've already done.  But let's rewind a little bit: The project is called Haiti Circle of Friends and it’s an orphanage.  Sort of.  The project manager, Barb, is trying to work family by family with the poorest families in this area, just outside the capital city, and get them back on their feet.  She does this in a variety of ways – by taking in children whose families cannot afford to take good care of them, by working with those families to teach them how to better care for their children, and by employing Haitians (often, the families of the children) to work for the orphanage, giving them a small source of income and hopefully preparing them to be self-sufficient.  Right now HaitiCOF consists of a house where I’m staying with another volunteer, five children, Barb herself and another one or two women who help take care of the kids; a small house that the project rents for the mother of three of the kids, one of whom lives with her now; a small plot of land that same woman is learning to farm – from which the house will gain vegetables and the woman will gain income, and two goats.  There were chickens, too, until last night. 

Sometime in the middle of the night last night someone came into the yard and took every single chicken.  No one heard but me, and I didn’t recognize the noises for what they were: distressed chickens here means theft.  It’s a nasty loss to the project, because it means replacing them at a cost of around $50, and it means until we do we have to buy the eggs we were getting from them.  Mostly, it’s a loss coming nastily on top of a much heavier financial burden: an unexpected hospitalization. 

I came to Haiti hoping to get to learn something about its health care system – but knowing that wasn’t my express purpose in coming so I might not see a lot of it.  Far sooner than I’d thought possible I got to experience it from the point of view of one of the COF children.  Barb told me on my first day the laundry list of ailments: malnourishment for all of them, developmental delays as well (probably related), skin diseases, anemia, and, in one case, kidney stones with a urinary tract infection.  This particular boy, Julio, had had kidney stones for some time, but had been passing one the other day.  Then he stopped peeing.  Because of the UTI, he had been drinking lots of water and cranberry juice – so dehydration wasn’t likely.   After the problem didn’t resolve in a day, Barb asked me to take him to the local clinic to see the doctor. 

The process of getting to see the doctor is a lot of waiting and more waiting.  We arrived around 11, and sat and waited.  There was lots of getting up and talking to people then sitting down again.  Finally the doctor actually arrived and the clinic staff arranged everyone into a line to see him – the line order must have been determined by something more complex than first come first serve, because we were first, but exactly what the order was I wasn’t sure.  We went in to see the doctor and it was painful for me to stumble through explaining things in French, then have Julio explain again in Kreyol, which I don't understand well, so I couldn't be sure if he was leaving things out.  He'd been so quiet, and so reluctant to go to the clinic.  The verdict, unfortunately, was a kidney stone blocking urination.  The doctor said maybe diuretics would work,  but without knowing for sure where the blockage was, they could also do more harm.  His first plan was to insert a catheter right then and there, see if that worked.  But apparently, the clinic had no catheters that day.  So instead he wrote out a full page, hand written referral for us to take to the hospital at Fermat for imaging, and impressed on me the urgency of the situation.  

There followed a harried hour or so in which I had to make contact with Barb and she had to come find us with the COF car so we could drive up to Fermat.  Fermat, it turns out, is a Baptist mission complex with a several clinics, a hospital, a place for mission groups to stay, a garden, cafeteria, and gift shop.  By this point we had both both Barb and Micalange, a Haitian woman who works at the house, with us so I was mostly superfluous – or so I thought until later.  We then began a strange process of first, finding someone to staff the clinic’s front desk area, then talking with them, going in to see the doctor (who tried to send us away, but Barb wouldn’t let him), trooping to the pharmacy to buy not just medications, but required equipment for injecting them, back to the doctor, back to the pharmacy where Barb bought a IV kit and several doses of intravenous antibiotics, to the hospital where they told us that the boy would have to be checked in for three nights.  This was an unpleasant surprise, since the doctor at the local clinic had implied everything could be done in an outpatient setting.  So we trooped back to the clinic, Barb shanghaied the doctor (there was a lot of Barb being pushy to get what she wanted out of people, I’m confident that if she hadn’t been, we would have at the very least been there twice as long, if not been completely refused) and he explained that since he was only a general practitioner, he wanted  to both treat Julio immediately and to keep tabs on him a few days until the urologist would be around.  

Now, to stay at a hospital in Haiti you have to bring your own food, drink, clothes, sheets, entertainment, everything.  And since Julio is only 12 we’d have to have someone stay with him. How COF was going to manage this with five other kids to watch over at home was a little bit of a struggle.   It was around this point we took a much needed lunch break - to anyone keeping track of the day, that was around 2:30/3:00. 

The final conclusion was that I would stay with him while Barb and Mica went back to the house to get everything needed.  So I spent about an hour sitting in the hospital corridor with a silent, sick, twelve year old who dosen’t speak my language and who hardly knew me.  He was extremely quiet, even when they put the IV drip into the back of his hand.  We did math problems on a sheet of paper the nurses gave us (when I asked really nicely and because they were so pleased I spoke French).  We stayed in the hall the whole time on a rickety bench that tipped when I stood up or sat down – because until the others came back there were no sheets for the bed.  The hospital is probably not that much bigger than my primary care doctor’s office back at home.  It was clean and decently staffed and painted bright green - but there were no doors on the wards, and the wiring was clearly not finished in some places.  Still, Julio seemed content enough once he was fully settled in and we'll just have to wait and see how the rest of his story plays out.  

Throughout the day I was struck by the contrasts in people's behavior: often polite, and seemingly helpful -yet things happen at a crawl.  The nurses at first glowered at me when Barb said I was staying with Marc, but then once they learned I spoke French I was welcomed.  One of them actually said to me "Welcome to Haiti" it was hard no to laugh, under those circumstances.  I hope to be able to write more as my time here goes on, but I'll leave you with the links to the project's website here and ask that if you can spare anything to help offset the costs of some of these unexpected expenditures, you look through it and give what you can.

To Dissect or Not to Dissect: Part I

One last set of thoughts on dissection (probably) before I move on to other things.   I wanted to take a minute to explore why we dissect, and why increasingly some schools don't.  There's a lot to say on this, so I'll split it arbitrarily into two parts.  First, a little background:

At my school, the gross anatomy course lasts only 16 weeks  - it's one of the first things we do, and is probably where we spend at least 50% of our time and energy for the first four months of medical school. This is faster than some.  Many schools prefer a complete 'organ system' method, in which the gross anatomy of a given organ or system is paired with physiology, biochemistry and histology of that same system.  This gives the students a whole view of each system - but means they grow more slowly to a whole body view.  In our first semester we do the very small (general biochemistry) and the very large, which we follow with a more systemically organized view starting in the winter we do histology and physiology of each system at a time.  However, first we spend four straight weeks on the neurological system.  This is the only course I have taken that encompasses anatomy, histology and physiology all at once.  It's all neuro, all the time, for four weeks.  Importantly for this discussion while we, the students, do all the dissections in gross anatomy we do not dissect anything in neuro.  We observe whole and sectioned brains prepared for us by the course staff, and use photographs and prepared slices to study the rest.  

So.  Why do medical students dissect at all?  With programs like Zygote body, VH dissector (a program created by the Visible Human Project at the national library of medicine, the program is licensed, so you can't play with it, but we had access at school), some would argue that there's no need.  And we're awful at it!  You can imagine that 170 first year medical students, most with no dissecting experience at all, are going to do some damage while they work - particularly if they are working in time-pressured circumstances.  The arguments for dissecting range from "it's the way I had to do it when I was in med school" to the slightly stronger "rite of passage" to the even more realistic: "real patients vary, you need to see real bodies to see variations."   However, medicine gets more and more complex every year: remember that really it's only two years of classroom teaching to take us from bio minor undergrads to clinical students able to recognize normal human physiology, and anatomy and to understand pathologies (at least theoretically).  So as time goes by, some schools have done away with hands on dissection - replacing it with prosection and guided reviews.  In this model, more experienced dissectors (TA's) do the work, presenting students with an excellently dissected specimen that they then can talk through and the students can explore.  Computer programs and pictorial textbooks can supplement.  In other countries school go even further and students dissect whole cadaver models that are artificially synthesized.

So which method is preferable?  Should we dissect everything ourselves?  Learn only using computer programs and books?  Try to encompass the best of both worlds with prosection and reviews? I'll express my opinion next week!  

Anatomy Mystery Part II

For the beginning of this story, see Anatomy Mystery Part I.  This is the story as it stands now,  with the information we learned just a few weeks ago:

Anatomy Mystery Part I

It seems I will be forever apologizing for not updating.  But I think this story is fascinating enough to make up for it.  It concerns the cadaver I dissected, along with seven of my classmates, back in September through November.  Below is only the first part, the part that happened back then: